Prediabetes Prevalence by Adverse Social Determinants of Health in Adolescents

Key Points Question How does youth-onset prediabetes prevalence differ by exposure to adverse social determinants of health (SDOH), independent of race and ethnicity? Findings In this cross-sectional study including a nationally representative sample of 1563 adolescents aged 12 to 18 years with obesity, the SDOH categories of food insecurity, lack of private health insurance, and lower household income were associated with higher prediabetes prevalence, independent of race and ethnicity. Meaning These findings suggest that adverse SDOH should be recognized in clinical settings and used to guide efforts to reduce risk of youth-onset type 2 diabetes.


Introduction
Type 2 diabetes (T2D) is a disease strongly influenced by poverty and structural racism. 1,2For the past 2 decades, a rapidly rising incidence in youth-onset T2D, particularly among American Indian or Alaska Native, Asian, Black, and Hispanic youths, 3 has highlighted the urgent need to prevent the onset of this severe disease, which leads to at least 1 microvascular complication by the third to fourth decades of life in 80% of individuals. 4One potential strategy to stem the tide of youth-onset T2D is to limit the development of youth-onset prediabetes, an intermediate glycemic state that is also associated with cardiometabolic comorbidities and obesity. 5,6Youth-onset prediabetes has more than doubled in prevalence in the past 2 decades and is now present in 28% of US adolescents overall and 40% of adolescents with obesity. 7Like youth-onset T2D, prediabetes is more common among racial and ethnic minority youths, 6 and it may be more likely to progress to T2D in non-Hispanic Black youths than in Hispanic or non-Hispanic White youths. 8wever, these epidemiological observations may be driven by social determinants of health (SDOH), which are conditions in which people grow, live, and work that are shaped by the distribution of money, power, and resources at global, national, and local levels. 2These conditions can be divided into 5 broad categories: educational access and quality, health care access and quality, neighborhood and built environments, economic stability, and social and community context. 2 Exposure to adverse SDOH differs by the social, nonbiological constructs of race and ethnicity. 2,9though previous studies have demonstrated associations between adult-onset T2D and adverse SDOH, 2,10 the potential interactive roles of race, ethnicity, and SDOH in youth-onset prediabetes have not been evaluated. 11,12Racial and ethnic minority youths are more likely to experience adverse SDOH related to income inequality, 13 so understanding the intersection between race and ethnicity and SDOH is critical to reduce T2D risk.This is particularly true for youths with overweight or obesity, who are at the highest risk for prediabetes and T2D. 14 address this gap, we evaluated differences in prediabetes prevalence by intersectional SDOH and race or ethnicity categories in a nationally representative sample of American adolescents who would be eligible for T2D screening based on age and body mass index (BMI)-based classification of overweight or obesity. 5We used the Healthy People 2030 SDOH domains 15 to guide our selection of measures available in the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2018.We hypothesized that adverse SDOH (food insecurity, lack of private health insurance, and lower household income) would be associated with higher prediabetes prevalence, both within and across racial and ethnic groups, partially explaining the observed racial disparities in prevalence due to higher rates of adverse SDOH among minoritized populations.

Study Population
The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.This cross-sectional analysis included youths aged 12 to 18 years with BMI at or above the 85th percentile for age and sex and with available hemoglobin A 1c (HbA 1c ) level measurements in 2-year survey cycle waves from 2011 to 2018 of NHANES.NHANES is a large program conducted by the National Center for Health Statistics that collects demographic, socioeconomic, and health-related surveys as well as physical measurements and clinical laboratory evaluations in a selected population that is designed to be representative of the US population after survey weighting.Administration of each NHANES questionnaire is based on participant age and sex, as relevant.Participants 16 years or older are interviewed directly, while an adult proxy (eg, parent or guardian) provided information on behalf of the survey participant for those younger than 16 years or who cannot answer questions themselves.
We began with data from the 2011-2012 cycle due to addition of a non-Hispanic Asian race and ethnicity category that began in that cycle, as Asian youth are at significantly increased risk of T2D.  based on evidence that marginal food security is associated with adverse child health outcomes 16 as well as with poor glycemic control in adult NHANES participants. 17To assess health care access, we used the Health Insurance Questionnaire to determine whether each individual had public, private, other, or no insurance.This variable was analyzed as any private insurance, only public insurance (or other, including single-service plans), and no insurance.The family poverty-income ratio, reported on the Demographic Questionnaire, was categorized by below 130% of the federal poverty level for that year (ie, <30% above the poverty level) or at or above 130%, consistent with eligibility for governmental assistance including the Supplemental Nutrition Assistance Program. 18

Race and Hispanic Ethnicity Categories
In NHANES, participants are given the option of self-identifying as Hispanic or Latino, including country of self or ancestral origin.Participants then self-identify race and are allowed to select multiple; if other race is selected, additional subcategories are presented, including Asian subcategories. 19The publicly available aggregated racial categories included non-Hispanic Asian, Black, and White, and more than 1 or other race (which could include American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and other), while ethnicity categories included Mexican American or Other Hispanic.

Outcomes: Adjusted Prediabetes Prevalence and Prevalence Ratios
Prediabetes was defined only by HbA 1c level due to the markedly smaller sample of adolescents with available fasting glucose levels and potential nonrepresentativeness of this small subpopulation.
Using American Diabetes Association criteria, 20 HbA 1c levels of 5.7% to 6.4% were considered consistent with prediabetes; 6.5% or greater, T2D (to convert to mmol/mol, multiply by 10.93 and subtract by 23.50).

Potential Confounders
We adjusted for age, sex assigned at birth, and relative obesity (BMI z score).The BMI z score was calculated using US Centers for Disease Control and Prevention pediatric growth curves 21 and the zanthro command in Stata, version 17 (StataCorp LLC).

Statistical Analysis
Demographic and clinical characteristics are reported using summary statistics and corresponding 95% CIs.We estimated associations between each SDOH and prediabetes prevalence using multivariable logistic regression models, adjusted for confounders.We included interaction terms for race and ethnicity and each SDOH.White race was used as the reference group due to being the largest racial or ethnic group.We calculated point estimates and 95%

Cohort Characteristics
Of  Prediabetes prevalence was higher among youth with food insecurity, public health insurance, and income to poverty ratio less than 130% of the federal poverty level (FPL) (P < .05for each comparison).insecurity compared with food security.Similarly, prediabetes prevalence was 5.3% (95% CI, 1.6%-9.1%)higher among youths with public compared with private insurance, though prevalence did not differ significantly between noninsured and privately insured youths (4.6% [95% CI, −1.2% to 10.3%]).Prediabetes prevalence was also 5.7% (95% CI, 3.0%-8.3%)higher among youths with household income at less than 130% of the federal poverty level compared with at least 130%.

Discussion
In this cross-sectional study including a nationally representative sample of adolescents with overweight and obesity, prediabetes prevalence was higher in the presence of adverse SDOH for the full subsample, but differing associations were found across racial and ethnic groups.To our knowledge, our study is the first to evaluate prediabetes prevalence in youth using intersectional race, ethnicity, and SDOH categories.This approach allowed us to isolate the association between prediabetes and each adverse SDOH while also highlighting how the association may differ by racial or ethnic identity.Our findings are similar to those from a cross-sectional study by Ogden et al 24 that demonstrated differing associations between obesity and household income among youth across race and ethnicity groups, with high household income associated with lower obesity prevalence among Asian and Hispanic youths, but no income-related difference among White and Black youths.
Similarly, a scoping review of associations between SDOH and health risk behaviors (eg, substance use, high-risk sexual behavior) among adolescents and young adults aged 10 to 24 years 25 found that associations differed across racial and ethnic groups and by SDOH assessed.These findings underscore the complexity of the associations among racial and ethnic identity, exposure to adverse SDOH, and health outcomes in youths.
Differences in T2D risk across and within racial and ethnic groups 26 emerge from factors at the individual, interpersonal, community, and societal levels. 27Youth-onset prediabetes results from a complex interplay across these levels, on an intergenerational scale.For example, risk of youth-onset obesity and insulin resistance is significantly higher among offspring of women with diabetes during pregnancy, 9,28 but this maternal risk differs by race and ethnicity 29 and is driven by exposure to adverse SDOH. 30,31Youth-onset obesity and prediabetes risk are reduced by engagement in healthpromoting behaviors, including physical activity and consumption of nutrient-dense foods; unfortunately, these health behaviors are often hardest to achieve for youths from communities which, due to oppressive policies and practices, have concentrated poverty and high rates of community violence. 9We also note that the prevalence of adverse SDOH in this cohort was relatively higher than the general population.Thus, our analytic approach of evaluating within-racial and ethnic group differences minimizes the confounding of associations between SDOH and prediabetes risk that occur due to differences in adverse SDOH exposure across racial and ethnic groups.
Our study also highlights differences in prediabetes prevalence among Asian youths, an understudied population at high risk for T2D. 32,33Asian American individuals are a heterogenous group, with vast differences in socioeconomic status, language identity, and immigration status both between and within cultural subgroups. 34Unfortunately, unrestricted NHANES data do not allow for disaggregation of this heterogenous group, an important limitation given the differing effects of SDOH within Asian subgroups.For example, educational attainment was found to be inversely associated with T2D risk among Filipino American adults, but directly associated with T2D risk among Indian American adults. 35Within Asian adults, those of South Asian extraction tend to be at highest risk, with T2D developing approximately 10 years earlier than among White adults. 36Adverse SDOH further exacerbate this risk: low household income is associated with higher prevalence of obesity among Asian American adolescents 37 as well as with prediabetes and T2D among Asian American adults. 38Disaggregating data could allow for better identification of drivers of health disparities within Asian and Pacific Islander communities, supporting the development of effective diabetes prevention interventions.

Strengths and Limitations
A major strength of our study is our evaluation of associations within racial and ethnic groups between adverse SDOH and prediabetes prevalence, which provided a less confounded estimate of associations.We observed consistently direct associations between adverse SDOH and prediabetes prevalence through analyses of individual, any, and cumulative adverse SDOH.Additional strengths

JAMA Network Open | Diabetes and Endocrinology
Prediabetes Prevalence by Adverse SDOH in Adolescents include the nationally representative sample of youths with rigorously and prospectively collected clinical and demographic data, including self-reported racial and ethnic identity.
This study also has some limitations.First, we did not include alternate, glucose-based prediabetes definitions.Although HbA 1c level has been reported to be higher among certain racial groups, 39 we defined prediabetes using HbA 1c because (1) an elevated HbA 1c level has been associated with development of T2D in diverse populations, including American Indian youth 40 ; (2)   it is guideline supported 5 and commonly used to screen for, diagnose, and manage T2D in youths 41,42 ; (3) it is not influenced by fasting and reflects longer-term glycemia 20 ; and, (4) our withingroup analysis minimizes concerns for between-race differences in glycosylation.Second, detailed family history was not available, so we could not adjust for this potential confounder.Third, we did not evaluate whether prevalence differences were associated with nutrition or physical activity.
However, in a study also using NHANES data, 43 diet quality was lowest among Black youths, independent of income, suggesting that diet may be an important factor explaining some of the observed racial differences in prediabetes prevalence.Fourth, NHANES aggregates individuals of other race and more than 1 race, an important limitation given the heterogeneity and increasing size of this population in the US. 44Fifth, adverse SDOH may be differentially reported by adolescents and caregivers, potentially leading to underestimation 45 or overestimation 46 of material needs.Last, this cross-sectional study does not allow us to determine causal relationships between SDOH and prediabetes.

Conclusions
In this cross-sectional study including a nationally representative sample of 1563 adolescents with overweight and obesity aged 12 to 18 years, we found that adverse SDOH, including food insecurity, lack of private health insurance, and low income were differentially associated with prediabetes prevalence across racial and ethnic groups.However, prediabetes prevalence remained high even in the setting of favorable SDOH among Asian, Black, and Hispanic youth.Other social and structural determinants of health, such as racism and ethnic discrimination, should be evaluated to determine whether the remaining disparities in prediabetes prevalence can be further explained to develop targeted approaches to T2D risk reduction.Furthermore, given the higher prevalence of prediabetes in the setting of SDOH, even in White youth who are not considered to be at high risk for T2D, 5 pediatric T2D screening guidelines should move beyond use of race and ethnicity and instead critically consider exposure to adverse SDOH. 47Such an approach would be well aligned with recent efforts by many pediatric health care organizations to make screening for health-related social needs standard of care. 48If successfully implemented, approaches that screen for and address adverse SDOH may ultimately reduce the risks associated with youth-onset T2D via prevention as well as early identification and treatment.

Figure .
Figure.Adjusted Marginal Prediabetes Prevalence Among Youth With Adverse Social Determinants of Health

JAMA Network Open | Diabetes and Endocrinology
More recent data from the 2019-2020 cycle are not considered to be nationally representative due to limitations in data collection during the COVID-19 pandemic, so were not included in this analysis.
JAMA Network Open.2024;7(6):e2416088.doi:10.1001/jamanetworkopen.2024.16088(Reprinted) June 11, 2024 2/11 Downloaded from jamanetwork.comby guest on 06/13/2024 22s of adjusted prediabetesprevalence by presence or absence of each adverse SDOH category (eg, food insecurity vs food security [reference group]; any vs no adverse SDOH) within racial and ethnic groups.Analyses were performed using Stata, version 17.All analyses incorporated appropriate sample weights22and used a 2-sided α = .05to indicate statistical significance.Due to repeated testing of the association between SDOH and prediabetes prevalence within multiple racial and ethnic groups 23 groups), false discovery rate-adjusted P values are reported.We used Stata survey procedures to ensure appropriate point and variance estimates for our study's population.Missing data were not imputed.Relative SEs were calculated to evaluate reliability of estimates; estimates with a relative SE of 30% or greater (less reliable) are reported herein.23Analyseswere performed from June 1, 2023, to April 5, 2024.

Table 1 .
Prevalence of Adverse SDOH by Race and Ethnicity a Unweighted sample sizes with responses for each measure included 1534 for food security, 1544 for health insurance, 1520 for income, and 1416 youths for any and cumulative SDOH.Data are from the 2011 to 2018 cycles of the National Health and Nutrition Examination Survey including youths aged 12 to 18 years with a body mass index at or above the 85th percentile without known diabetes.P < .001forall between-group differences.bOther includes American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and other race.c Estimate may be less reliable owing to a relative SE of 30% or greater.

Table 2 .
Prediabetes Prevalence by Intersectional Adverse SDOH Status and Racial and Ethnic Identity a Unweighted sample sizes with responses for each measure included 1534 for food security, 1558 for health insurance, 1420 for income, and 1416 youths for cumulative SDOH.Multivariable logistic regression models were adjusted for age, sex, body mass index z score, and survey cycle.Data are from the 2011 to 2018 cycles of the National Health and Nutrition Examination Survey including youths aged 12 to 18 years with a body mass index at or above the 85th percentile without known diabetes.bOther includes American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and other race.cFalse discovery rate-adjusted P value for comparisons within each of 6 racial and ethnic categories; reference category is the most advantaged group.d Estimate may be less reliable owing to relative SE of 30% or greater.